Patients Requiring Valve Surgery Research Articles

Combined Mitral and Aortic Valve Surgery: 17-year Experience in a Single Center.

Background and objective:It is not uncommon that patients requiring valve surgery have several simultaneous valvular dysfunctions. Combined aortic and mitral valve surgery is the most common form of double-valve surgery. The aim of this study was to analyze and present the outcomes of simultaneous aortic and mitral valve surgery in a single center in a real-life setting.Methods:The study population consisted of 150 patients operated in the Kuopio University Hospital from 2004 to 2020. All patients undergoing concomitant mitral and aortic valve surgery were included. Four groups were formed based on either the etiology or pathophysiology of the valvular dysfunction. The most common combination was mitral regurgitation with aortic regurgitation (n = 72, 48%), followed by mitral regurgitation with aortic stenosis (n = 37, 25%), endocarditis (n = 29, 19%), and mitral stenosis with aortic regurgitation or stenosis (n = 12, 8%). Concomitant coronary artery revascularization was performed in 37 (25%) patients and tricuspid valve repair in 26 (17%) patients.Results:Operative mortality was 2% and 30-day mortality was 7%. Overall survival was 86%, 78%, and 61% in 3, 5, and 10 years, respectively. Patients with endocarditis were significantly more morbid, and more often than other patients had to undergo an emergency operation. There were no significant differences between the groups in terms of early and late survival. In the overall cohort, the EuroSCORE II value, increased pulmonary artery pressure, decreased glomerular filtration, and length of the operation displayed a negative correlation with survival.Conclusions:Despite the challenging nature of multivalvular heart disease, surgery is a safe method of treatment with good short- and long-term outcomes.

MitraClip: a word of caution regarding an all too liberal indication and delayed referral to surgery in case of failure.

Although indications for the MitraClip are becoming increasingly liberal, the number of patients requiring valve surgery after an insufficient outcome of the procedure is growing. Referral to surgery is, however, frequently delayed. During this time, the patients often deteriorate. We retrospectively analysed patients before MitraClip implantation and after mitral valve surgery. A total of 49 patients who received a mitral valve replacement (average 8 ± 12 months after MitraClip implantation) were assessed. Of these, 53% had 2-4 clips inserted. The mean age was 73 years, and the mean log EuroSCORE was 20.79 ± 14.42%. Echocardiographic data obtained prior to MitraClip implantation and preoperatively, 10 days and 6 and 12 months after cardiac surgery were reviewed. Survival analysis, risk profile and postoperative complications were analysed. The 30-day and 1-year mortality was 26.5% and 59.2%, respectively. Prior to MitraClip implantation, 42.8% of patients had mild tricuspid insufficiency and 6.1% had moderate tricuspid insufficiency. Prior to surgery, 26.5% showed mild, 32.7% moderate and 38.8% severe tricuspid insufficiency (P < 0.001). Furthermore, right heart function assessed by tricuspid annular plane systolic excursion deteriorated significantly after Implantation of the MitraClip (P < 0.001). In patients with a MitraClip, the pulmonary artery pressure was significantly higher at the time of mitral replacement than it was before the MitraClip was implanted (P < 0.001). A subgroup of patients does not benefit from a MitraClip and shows progressive deterioration in cardiac function, making valve replacement under difficult circumstances inevitable. The earlier these patients are operated on, the better it is. It can be assumed that some patients would be better off with primary surgery, especially if mitral reconstruction is then still feasible. Therefore, the indications for MitraClip implantation should be carefully considered and caution should be exercised during monitoring.

Analysis of the frequency of bacteraemia of dental origin implicated in infective endocarditis in patients requiring valve surgery

Understanding the frequency of bacteraemia of dental origin that is implicated in severe infective endocarditis (IE) will further our understanding of the disease’s pathoaetiology and help us take steps to reduce its prevalence. A total of 78 patients from the Royal Papworth Hospital, Cambridge, who had valve surgery due to IE (as confirmed by the Modified Duke Criteria) were included. Case notes were retrospectively reviewed for microorganisms that were implicated in the bacteraemia and IE. Associated factors were also recorded to determine whether they were different if a dental or non-dental pathogen was inoculated. A dental pathogen was implicated in 24 of the patients with IE; 20 had non-dental pathogens, and 30 were culture negative. This was not deemed statistically significant (p=0.54). Of the associated factors, only smoking was statistically significant with a greater proportion of non-smokers having bacteraemia of dental origin (p=0.03). No other associated factor was appreciably different based on the aetiology of the microorganism. Our results indicate that dental pathogens are not more likely to cause severe IE. We therefore advocate the stance adopted by the current national guidance on the judicious prescription of antibiotic prophylaxis for IE with regard to dental procedures.

Does Additional Coronary Artery Bypass Grafting Increase Hospital Mortality of Patients Requiring Valve Surgery?

Background: The aim of this study was to evaluate the impact of additional coronary revascularization on the early results in patients submitted to valve surgery. Patients and Methods: A retrospective review of the cardiac surgical database between January 2000 and December 2018 was performed. A total of 1667 patients were included and divided into two groups: Group A isolated valve surgery (IVS n = 1608) and Group B with valve surgery combined to coronary artery bypass grafting (VS + CABG n = 59). Demographic, operative data and postoperative outcomes were compared between groups. Results: Patients with combined procedure were older than patients who underwent isolated valvular surgery (64.9 ± 9.2 years vs 44.4 ± 13.1 years; p = 0.0001) and there was a higher proportion of diabetics (40.7% vs 6.6%; p = 0.0001). The 30 days mortality rate in the combined procedure group was 18.6% versus 6.2% in isolated valve surgery (p = 0.001). Also post-operative complications were more frequent than for patients who underwent IVS. Additionally we noted a high prevalence of coronary artery risk factors in patients with combined procedures. Conclusion: Surgical mortality and morbidity of coexisting coronary and heart valve disease were substantially higher than IVS. More efforts in medical management may reduce the incidence of adverse outcomes.

The Temporospatial Epidemiology of Rheumatic Heart Disease in Far North Queensland (1997–2017)

Background: Rheumatic heart disease (RHD) is still being diagnosed in Australia. It is essential to define the temporospatial epidemiology of the disease to inform strategies for its prevention. Methods: Individuals diagnosed with RHD in Far North Queensland (FNQ) between 1997 and 2017, were identified using the RHD register and public health system data. Results: There were 686 individuals diagnosed with RHD during the study period. Their median age at diagnosis was 29 (Interquartile range (IQR) 17–44) years; 458 (66.8%) were female; 616 (89.8%) identified as Indigenous Australians. The incidence of RHD increased in FNQ from 4.7/100000/year in 1997 to 49.4/100000/year in 2017 (p < 0.001). RHD incidence increased in both metropolitan and rural and remote locations, but it was significant higher in rural and remote locations (median (IQR) 44.6/100000/year (20.3–90.7) versus 5.9/100000/year (1.3–10.4), p < 0.001). There were 388 individuals with RHD receiving secondary prophylaxis (367 (94.6%) parenteral penicillin and 21 (5.4%) oral therapy). The median (IQR) adherence to parenteral secondary prophylaxis was only 41% (23–58%). The number of separate patients requiring valve surgery increased from 52 (41.9%) patients between 1997–2007 to 72 (58.1%) between 2008–2017 (p = 0.03). Conclusion: The incidence of RHD and incidence of RHD-related surgery continues to rise in FNQ. Although this is likely to be partly explained by increased disease recognition and enhanced service delivery, the incidence of the disease remains unacceptably high and is disproportionately borne by the Indigenous population. Optimisation of primary and secondary prophylaxis is urgently required to reduce the burden of this preventable disease.

Republished: Drug-induced valvular heart disease

Drug-induced valvular heart disease (DIVHD) was first described in the 1960s. Initially, associations with ergot derivatives used for migraine prevention, or with anorectic drugs, were described. Drugs used for the...

Elevated parathyroid hormone predicts mortality in dialysis patients undergoing valve surgery

Dialysis patients requiring valve surgery have high morbidity and mortality rates. Although elevated serum parathyroid hormone (PTH) levels are associated with increased mortality in dialysis patients, this correlation has not been investigated in patients undergoing cardiac valve operations. This study assesses the impact of PTH levels on mortality in dialysis patients undergoing valve operations. A retrospective analysis of 109 dialysis patients undergoing valve operation with preoperative PTH levels between 1996 and 2007 at a US academic center was performed. Cox regression analyses were done using PTH as a binary variable. The patients were followed from the date of the operative procedure until death or loss to follow-up. Higher mortality risk was seen once preoperative PTH exceeded 200 pg/mL (hazard ratio [HR], 3.43; P = .003). Mean survival was improved in the PTH < 200 pg/mL group when compared with the PTH ≥ 200 pg/mL group (86.7 vs 40.3 months, respectively). Other independent predictors of mortality included serum phosphate (HR, 1.20; P = .017), calcium-phosphate product (HR, 1.02; P = .038), and history of myocardial infarction (HR, 2.12; P = .015). Preoperative PTH level ≥ 200 pg/mL is predictive of increased mortality after valve surgery among dialysis patients. Hyperparathyroidism should be investigated further as a possible modifiable risk factor for postoperative mortality in this high-risk patient cohort.

Bicuspid aortic valve phenotype and aortic disease: a magnetic resonance study

Objective The aim of this study was to uncover any association between bicuspid aortic valve (BAV) phenotype and aortic valve disease or aortic dilation. Background BAV is the most common congenital heart defect in the general population, particularly in patients requiring valve surgery. Recent studies have shown cardiovascular magnetic resonance (CMR) to be an accurate and sensitive modality for classifying BAV phenotypes. Methods Patients were selected retrospectively from the database at NMH according to IRB-approved protocols. We identified and selected 217 patients who had a diagnosis of BAV and underwent CMR angiography between 2007 and 2010. For each subject, age, gender, functional state of the BAV, pattern of fusion, aortic root diameter, mid ascending aortic diameter, proximal and distal aortic arch diameter, and primary indication at the time of the MRA were extracted from reports. Results We identified four valve morphologies: type 1, fusion of the right and left cusps (n=152); type 2, fusion of the right and non-coronary cusps (n=48); type 3, fusion of the left and non-coronary cusps (n=9); and unicuspid, two fusions (n=8). We further characterized each type by the number of sinuses, two or three, and the presence or absence of a raphe. Comparing the three types, two sinuses were associated with a significantly higher (P<0.001) proportion among type 2 and type 3 BAV. Type 2 BAV was associated with moderate to severe stenosis (P=0.049) and a larger diameter of the mid

Variable phenotypes of bicuspid aortic valve disease: classification by cardiovascular magnetic resonance

BackgroundRecently, cardiovascular magnetic resonance (CMR) has been shown to allow accurate visualisation and quantification of aortic valve disease. Although bicuspid aortic valve (BAV) disease is relatively rare in the general...

Surgical Challenges in Rheumatic Heart Disease in the Australian Indigenous Population

Acute rheumatic fever, leading to rheumatic heart disease (RHD), is rare in Australia except amongst Aboriginal and Torres Strait Islander people. Cardiac surgical procedures performed at Flinders Medical Centre on patients from the Top End of the Northern Territory from 1993 to 2008 were reviewed. This study compared Indigenous and non-Indigenous patients on short term morbidity and long term survival employing logistic regression and Cox proportional hazard models. We also outline the challenges of managing Aboriginal patients, as our unit services vast areas of northern Australia inhabited by Indigenous people. The total number of patients from the Northern Territory was 835. Amongst the Indigenous patients, there were 235 (55.6%) isolated coronary artery bypass graft procedures, 171 (40.4%) patients underwent isolated valvular surgery (91 mitral and 80 aortic), and 17 (4.0%) underwent combined valvular surgery with coronary artery bypass graft surgery. Aboriginal patients requiring valve surgery are younger and have greater comorbidity than non-Aboriginal people. Short term surgical results are similar to non-Aboriginal people but long term outcomes appear to be inferior. Age and socioeconomic conditions of Indigenous patients need to be considered. Cultural issues should be understood and acknowledged and surgery better focused around surgical units with appropriate infrastructure.

Outcome of Patients Requiring Valve Surgery During Active Infective Endocarditis

The optimal timing of cardiac operations in patients with infective endocarditis continues to be debated. This observational study analyzed the profile and outcome of patients with active infective endocarditis undergoing operations. Between June 2000 and June 2006, 95 surgically treated patients with definite infective endocarditis by the modified Duke criteria were included. Fifty-eight patients were operated on within the first 7 days after diagnosis of infective endocarditis and 37 at more than 7 days after diagnosis up to immediately after completion of antibiotic treatment. Staphylococci predominated and were significantly associated with embolism, abscess, and septic shock. The most frequent indication for operation was severe regurgitation with heart failure. The 6-month mortality was 15%. Early operation showed a trend towards increased mortality vs late operation. In univariable analysis, factors associated with 6-month mortality included staphylococci and septic shock. Multivariable analysis revealed that septic shock predicted 6-month mortality. Despite early operation in patients experiencing septic shock, 57% died. No patients without heart failure died after undergoing (early or late) procedures for severe regurgitation. The prognosis in surgically treated patients was determined by the occurrence of septic shock. The outcome in patients who underwent late operations was favorable compared with the early group. This difference was probably not due to the timing of the surgical intervention but to the severity of infective endocarditis. In patients with severe regurgitation without heart failure, early operation may offer benefit in length of hospitalization and prevention of development of new heart failure.